Choose the Right Treatment for Advanced COPD

Medically Reviewed by Paul Boyce, MD on February 06, 2019
4 min read

Some simple tests can help your doctor know how to help you breathe easier, keep you out of the hospital, and boost your quality of life.

People with more advanced COPD often need a combination of treatments, says Albert A. Rizzo, MD, chief medical officer of the American Lung Association. Those may include inhaled medications or medicines you take by mouth, antibiotics, oxygen therapy, pulmonary rehab classes, and, in more severe cases, surgery.

Your pulmonologist will put your COPD in one of four stages based on your symptoms and quality of life. The current Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines help your doctor figure out the stage of your COPD and choose the therapy that’s right for you. They’re based on:

  • How well you fill up and empty your lungs
  • How COPD symptoms affect your life
  • Your chances, now or in the future, of more severe problems or a hospital stay
  • Any other health problems you have


Spirometry is a test that shows how fast you can fill your lungs with air and then empty them. It can tell your doctor how much COPD has narrowed the airways in your lungs and help them pick the best treatments for you or see if you need to change your current therapy.

You’ll breathe in through a mouthpiece as deeply as you can. Then you’ll empty your lungs as fast as you can. Your doctor will guide you as you take the test a few times.

Your spirometry score is based on two measures: forced expiratory volume (FEV1) and forced vital capacity (FVC). FEV1 is how much air you breathe out of your lungs in the first second and how quickly you exhale it. FVC is the total amount of air you push out of your lungs during the test.

You can do your spirometry test after you’ve taken a dose from your short-acting bronchodilator inhaler.

If your FEV1 score is between 50% and 30%, your COPD is severe. If your FEV1 is less than 30%, you have very severe COPD.

Other tests can show how much COPD has narrowed your airways and made it harder for you to breathe:

  • Chest X-ray
  • Computerized tomography (CT) scan. This is a series of X-rays taken from different angles to show a more complete picture of your lungs.
  • Arterial blood gas test. This shows how well your lungs work to put oxygen into your blood and take out carbon dioxide. A small sample of your blood will be taken from your wrist, the inside of your arm, or your groin.

A CT scan is the best type of imaging scan to use to see if COPD has narrowed your breathing passages, says Jason Turowski, MD, a pulmonologist at the Cleveland Clinic in Ohio.

“By using a CT scan, we can develop a 3D map of your airways. Your lungs are mostly air, so we need a CT scan to get the lay of the land inside them,” he says.

To find the right treatment for you, your pulmonologist probably will ask you to fill out a couple of simple questionnaires. Your honest answers help your doctor understand how much COPD affects your life, Rizzo says.

  • The Modified British Medical Research Council (MMRC) questionnaire ranks how breathless you get with normal activities, like getting dressed or walking up steps, on a scale of 0 to 4.
  • The COPD Assessment Tool (CAT) questionnaire is more detailed. It measures how often you cough, your level of chest mucus and tightness, how breathless you get with normal exercise, how well you sleep, and if your activities are limited because of COPD symptoms.

Your doctor will also talk with you about your daily habits. Tell them if you still smoke or are around someone who smokes. Let your doctor know if you’re often around a lot of dust, air pollution, or chemicals at home or at work. Talk about your symptoms, including how often you have problems like shortness of breath, coughing, or trouble sleeping.

“If your COPD flare-ups are more severe, you might need oral antibiotics or prednisone, a steroid,” Rizzo says. “If your sleep is disrupted a lot because you cough more, it’s important to know why. Is this because of COPD, or do you have another sleep disorder, like sleep apnea?”

Talk with your pulmonologist about all your treatment options and their possible side effects. For example, inhaled steroids may make you more likely to get bruises or oral infections. Oral steroids, if you use them for a long time, can weaken your bones or cause diabetes, cataracts, weight gain, and other problems. Phosphodiesterase-4 inhibitors like roflumilast (Daliresp), a newer drug for severe COPD, may cause weight loss and diarrhea.

Your pulmonologist may also want to make sure you can easily use an inhaler, oxygen tank, or mouthpiece, or any other device that delivers your COPD treatment.

“These devices are all different and require you to manipulate them with your hands,” Rizzo says. “I watch how my patient uses it in the office. No matter how good a drug is for COPD, if you’re not able to use the device, it’s no good.”

Your doctor also may consider cost and your insurance coverage to select COPD treatment for you. Pulmonary rehab, which includes nutrition and exercise counseling, works well for many people with advanced COPD, but your policy may limit how many sessions are covered.